The aim of this retrospective study was to correlate the width of the cleft lip with the severity of the nasal deformity in unilateral cleft lip and palate (UCLP) patients before primary lip repair. Preoperative impression casts were made. Measurements were taken of the width of the cleft lip (CW), nose (NW), and nasal floor (NFW), alar base height (ABH), columella length (CL), nasal length (NL) and nasal tip protrusion (NTP). The ratio of the non-cleft side (NFW) to the cleft side (NFWR), the ratio of the non-cleft side (ABH) to the cleft side (ABHR), and the ratio of the cleft side (CL) to the non-cleft side (CLR) were calculated. The average NW, NL and CW were higher in the group with complete clefts. There was a negative linear relationship between CW and NFWR, and a positive linear relationship between CW and ABHR in the complete group. In the incomplete group, negative correlations were obtained between CW and NFWR and between CW and ABHR. These findings show that there are correlations between CW and the transverse and vertical imbalance of nose in both groups but not between CW and anteroposterior imbalance of nose.
The goals of primary repair of cleft lip/nasal deformity should include the anatomatic and functional reconstruction of the lip and the nose . A well repaired cleft lip can often be distracted by an imperfect nasal repair. Many techniques have been devised to avoid this suboptimal outcome, but their success depends on the degree of deformity and dissymmetry of the cleft lip/nasal deformity before surgery.
Unilateral cleft lip is always associated with nasal deformity. It is generally assumed that the wider the lip cleft the more severe the nasal imbalance, but the authors have found this is not always true. They reviewed the literature and found many studies of the cleft nose and lip after primary lip repair . There have been few anthropometric studies of the cleft lip and associated nasal deformity before primary lip repair , especially concerning the relationship between the cleft lip and nose before surgery.
F arkas established a series of standard anthropometric facial landmarks in the 1980s. Since then facial plaster casts have been used for various purposes. They are simple, economic and widely available. When the cast is marked with standardized anthropometric landmarks, it allows for precise measurements of the soft tissue directly in all three dimensions.
The aim of this study is to utilize established anthropometric methods in conjunction with facial casts from preoperative unilateral cleft lip/palate patients to establish the precise relationships between the lip deformity and the nasal deformity.
Patients and method
Infants with unilateral cleft lip, with and without involving the palate (UCL ± P) were retrospectively enrolled in this study. Plaster casts of the faces in 110 UCL ± P patients, taken preoperatively, were selected in date order of presentation for surgery in the authors’ department. The 110 UCL ± P patients underwent primary lip repair at ages from 6 months to 8 months between 2004 and 2006. Among the 110 cleft children, 69 were complete UCLP patients, and 41 were incomplete UCL ± P patients. The mean age of the complete group was 6.95 months, and the incomplete group was 6.96 months. There was no significant difference between complete and incomplete groups in age ( T = 0.082, P = 0.935). No patients had received orthodontic treatment before primary lip repair.
The selection criterion for complete UCLP in this study is no tissue bridge exists in the lip, alveolar and palate cleft. For incomplete UCL/P, the selection criteria are: presence of a tissue bridge more substantial than a Simonart’s Band; and the palate is intact or the cleft palate is not beyond the incisive foramen. The exclusion criterion for incomplete UCL/P is only the vermilion is cleft.
The authors took impressions when the patients had undergone general anesthesia before surgery, taking care to avoid tissue distortion. The plaster cast was made as soon as the impression was ready. All 110 casts included the labial commissure and endocanthion on both sides, and the anatomical points were clear. Broken or incomplete casts were eliminated.
For the purpose of this study, seven parameters were used. Six nasal measurements were selected as key features to define the severity of the nasal deformity: nasal floor width ratio (NFWR), nasal floor width on the non-cleft side/nasal floor width on the cleft side; alar base height ratio (ABHR), alar base height on the non-cleft side/alar base height on the cleft side; columella length ratio (CLR), columella length on the cleft side/columella length on the non-cleft side; nasal width (NW); nasal length (NL); and nasal tip protrusion (NTP). Three of the previous parameters represent nasal imbalance in three axes: transverse (NFWR), vertical (ABHR) and anteroposterior (CLR). NL, NW and NTP are the conventional parameters to describe the nasal shape. The width of the cleft lip (CW) represents the lip deformity.
To measure the parameters, standardized labial and nasal landmarks should be defined in terms of Farkas’ description ( Fig. 1 ). The three-dimensional (3D) point-to-point distance measurements on the surface of the casts were used for all parameters except for ABHR. A digital sliding caliper was used to diminish the error. The ABHR was measured on the frontal photograph of the cast because it was difficult to mark a perpendicular line from the alar base to the transverse plane on the cast. The other reason for using the photograph to measure ABHR was that it accurately reflects the vertical features of the nose. The same person measured all the parameters three times and determined the average value. The alar base height was defined as the distance between the point sbal and the line connecting the medial canthus. CW was the distance between the point where the red line and the white skin roll of the lip connect each side. The measurement parameters are shown in Figs. 2 and 3 .
Statistical analysis was completed using the SPSS 11.0 statistical software platform. The mean, standard deviation and range of values of the seven parameters were calculated in both groups. The mean values between the two groups were compared using Student’s t -test, except for CW where the Mann–Whitney W -test was used because the data did not fit the normal distribution. The relationships between the lip deformity and nasal deformity were also analyzed in both groups.
Mean values and range of values
The mean values for NFWR, ABHR, CLR and NTP were smaller in the complete cleft group. The mean values of NW, NL and CW were greater in this group. These differences were statistically significant (NFWR: P = 0.000; ABHR = 0.001; CLR = 0.000; NTP = 0.004; NW = 0.000; NL = 0.004; CW = 0.000). Means and ranges of values for all parameters in complete and incomplete clefts are shown in Table 1 .
|Range of values||13.3–57.63%||31.27–83.65%|
|Range of values||76.84–100%||89.02–104.31%|
|Range of values||2.66–93.42%||30.91–114.37%|
|Range of values||6.02–11.22||6.44–11.12|
|Range of values||30.8–42.25||26.51–39.1|
|Range of values||16.16–23.92||16.06–26.38|
|Range of values||3.15–15.47||1.18–6.22|